One of the most basic of human rights is healthcare. When we talk about documenting appropriately in healthcare, we must keep in mind that documentation is the second step in the process. The first step is the collection of information through subjective discussions with our patients.
We, as providers, must be non-judgmental in communicating with our patients in order to capture the most comprehensive information to provide appropriate, effective, and efficient care. We must allow our patients to be comfortable in communicating their healthcare problems, concerns, and needs.
I have practiced obstetrics and gynecology for a number of years, and therefore have learned to be comfortable in almost any environment – especially regarding discussing sexuality in patients. It is very important for patients to be comfortable and honest with me, but it is also significantly important for me to feel comfortable with my patients, no matter their sexual orientation. Specificity can only be captured through openness to, and with, our patients. For some providers, openness does not have to equal acceptance, but it must equal respectfulness, candor, and honesty.
When documenting (and coding) for transgender individuals, there are some ICD-10 codes, for example: Z87.890, personal history of sex reassignment; F64.0, transsexualism; and F64.1, transvestism. It is becoming more important to document birth sex, or genetic gender, as well as gender identity. Utilization of the sexual assignment codes will help with conflicting data, such as the reality of anatomical gender identity – females cannot have prostate cancer, but males can have breast cancer. Also, birth-sex males are 25 times more likely to develop inguinal hernias than birth-sex females, and females are incapable of suffering testicular torsion. Keep in mind that patients are all just looking for care as human beings, and treatment reflecting as such. Therefore, the most appropriate way to document gender is to capture whether a patient is transgender, and then the anatomical birth sex, as well as the current specific gender identity. This best meets both the needs of the patient and the documentation system, within which we must work. The medical record must be evidence-based, factually based, but inclusive of the sensitivities and preferences of our patient.
When I was in clinical practice, I had a significant lesbian and bisexual population. Even before patients were “coming out,” distinct, unique needs were self-evident. This guided my thinking, as well as my practice, toward being non-judgmental. One of the points that was very evident was that no matter their sexual orientation, patients just want to be treated and respected as human beings, no more and definitely no less. I must admit that I had challenges initially in providing care for transgender patients. But I soon found out that even though there was nothing I could do for them gynecologically, they were coming to an environment that they hoped would be accepting and safe.
I am sorry to this day that I never at least talked to the first transgender patient who came to my office (I had her sent away by my staff). I turned her away because I felt that there was nothing I could do for her. After that time, I have talked to transgender patients upon presentation to my office, and found that there was just basic medical care that was needed – not gynecological. Such patients usually just wanted to come to an environment where they did not feel judged. This is what we all should be allowed to have in life – no more and definitely no less.
An update to the 2022 Query Practice Brief was released for comment last week during the 2026 National Association of Clinical Documentation Integrity Specialists (ACDIS)
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